New Test | Grove Dental Associates

WELCOME,
FROM CAPULIN CREATIVE

We are so glad you’ve trusted us to help you with your business. Below, you’ll find forms to submit blog post requests, social media content, and new project requests. If you have any questions, please reach out!

Capulin Creative may be reached at:

Your Content

Start New Project
Blog Post Request
Logo Files
Brand Guidelines
Print Files
Digital Files
Photos
Resources
Media Content
Website Manual

New Project Request

Please use this form to request new projects from Capulin Creative

Oops! We could not locate your form.

Blog Post Request

Please use this form to request new projects from Capulin Creative

NEW PATIENT INFORMATION
ABOUT YOU
Patient Name:*

(First)
Middle Name

(Middle)
Last Name*

(Last)
Name Prefix
- Mr.
- Mrs.
- Ms.
- Dr.
I prefer to be called:
Sex :
Sex:
- Male
- Female
Birthday*
Birthday
MM slash DD slash YYYY
Address*
City*
State*
Zip*
Home Phone:
Work:
Cell:
Social Security #:
Email:
Employer:
Occupation:
Emergency Contact:
Emergency Phone #:
SPOUSE INFORMATION
No spouse information
- No spouse information
Spouse's Name
Spouse's Employer:
Primary Phone #:
Birthday:
MM slash DD slash YYYY
DENTAL INSURANCE
We will gladly assist you in filing the claims for your primary insurance if provided with the necessary information and a copy of the insurance card.
Mark for no dental insurance
- Mark for no dental insurance
Full name of the Policy Holder
Policy Holder SS#:
Policy Employer:
Policy Holder Birthday:
Relationship to Policy Holder:
Name of Insurance Company
Insurance Group #:
Member ID#:
Signature:
Date:
I understand that payment is expected on the day of each service. I realize I am also responsible for any remaining charges that my insurance company chooses not to pay.
REFERRED BY
Name of Referral:
Relationship of Referral:
Referral By:
- Phone Book
- Newspaper
- Radio
- Website
- Facebook
- Other
DENTAL HEALTH INFORMATION
When was your last dental visit?
Name of previous dentist:
Do you have any current dental issues or concerns you would like to discuss or address
What (if anything) would you like to change about the appearance of your smile?
Do you have any fears about visiting the dentist (pain, cost, previous bad experience, lack of time, etc.)?
On a scale of 1 to 10 how would you rate your dental health? (1 being poor, 10 being excellent)
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
MEDICAL INFORMATION
Name of Primary Physician:
Date of last visit:
Any recent illness/doctor care or surgeries, please list:
List all medications you are currently taking:
Are you currently or have you ever taken any medication or bisphosphonates for osteoporosis?
- Yes
- No
All medical allergies
Other allergies:
Have you been told that you require antibiotic pre-medication prior to dental treatment?
- Yes
- No
Why?
Pregnant
- Yes
- No
Nursing
- Yes
- No
Taking birth control pills
- Yes
- No
Have you ever been treated for or experienced any of the following? (Please check all that apply.)
- Sleep Disorder/Apnea
- CPAP Therapy/Machine
- Daytime Sleepiness
- Acid Reflux
- Clenching/Grinding of Teeth
Do you have a history of any of the following? (Please check all that apply.)
- AIDS
- Cortisone Treatments
- HIV Positive
- Respiratory Disease
- Anemia
- Diabetes
- Jaw Pain
- Rheumatic Fever
- Arthritis
- Epilepsy
- Kidney Disease
- Scarlet Fever
- Artificial Heart Valve
- Fainting
- Latex Allergy
- Seizures
- Artificial Joints
- Glaucoma
- Liver Disease
- Shortness of Breath
- Asthma
- Headaches
- Mitral Valve Prolapse
- Stroke
- Back Problems
- Heart Murmur
- Nervous Problems
- Swelling of Feet/Ankles
- Blood Thinners
- Heart Problems
- Pacemaker
- Thyroid Problem
- Cancer
- Phen-fen or Diet Pills
- Tobacco Habit
- Chemical Dependency
- Hemophilia
- Prolonged Bleeding
- Tuberculosis
- Chemotherapy
- Hepatitis
- Psychiatric Care
- Ulcer
- Circulatory Problem
- High Blood Pressure
- Radiation Treatment
- Venereal Disease
Describe Your Heart Problem:
Other:
HIPAA FORM
- I HAVE BEEN OFFERED AND/OR RECEIVED A COPY OF GROVE DENTAL ASSOCIATES’ NOTICE OF PRIVACY PRACTICES
- I UNDERSTAND THAT MY PHI (PROTECTED HEALTH INFORMATION) CAN AND WILL BE USED FOR PURPOSES OF TREATMENT AND FOR PAYMENT FROM BOTH MYSELF AND/OR THIRD PARTY. I UNDERSTAND THAT I MAY REQUEST A COPY OF THE PRIVACY POLICIES AT ANY TIME.
- I UNDERSTAND I MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT
I GIVE CONSENT FOR THE OFFICE OF GROVE DENTAL ASSOCIATES TO SHARE PERSONAL INFORMATION REGARDING APPOINTMENTS, TREATMENT, BALANCE, ETC, WITH THE FOLLOWING FAMILY MEMBERS/SPOUSE/FRIENDS/OTHER.
PLEASE LIST NAME / RELATIONSHIP AND SIGN BELOW OR PLEASE WRITE NO ONE IF YOU DO NOT WANT YOUR INFORMATION SHARED WITH ANYONE,
1. Name / Relationship
2. Name / Relationship
3. Name / Relationship
PRINT PATIENT NAME

PRINT PATIENT NAME
PATIENT SIGNATURE OR PARENT/GUARDIAN SIGNATURE IF PATIENT IS A MINOR (UNDER 18)

PATIENT SIGNATURE
OR PARENT/GUARDIAN SIGNATURE IF PATIENT IS A MINOR (UNDER 18)
Date

Date
CAPTCHA

Logo Files

PLEASE SELECT AN ITEM

Direct download will begin once you select from the list below

Item Name Here
Item Name Here
Item Name Here
Item Name Here

Brand Guideline

PLEASE SELECT AN ITEM

Direct download will begin once you select from the list below

Item Name Here
Item Name Here
Item Name Here
Item Name Here

Print Files

PLEASE SELECT AN ITEM

Direct download will begin once you select from the list below

Item Name Here
Item Name Here
Item Name Here
Item Name Here

Digital Files

PLEASE SELECT AN ITEM

Direct download will begin once you select from the list below

Item Name Here
Item Name Here
Item Name Here
Item Name Here

Digital Photos

PLEASE SELECT AN ITEM

Direct download will begin once you select from the list below

Item Name Here
Item Name Here

Digital Resources

PLEASE SELECT AN ITEM

Direct download will begin once you select from the list below

Item Name Here
Item Name Here

Media Content Form

NEW PATIENT INFORMATION | Minor Child
ABOUT YOU
Patient Name:*

(First)
Middle Name

(Middle)
Last Name*

(Last)
I prefer to be called:
Sex :
Sex:
- Male
- Female
Birthday*
Birthday
MM slash DD slash YYYY
Address*
City*
State*
Zip*
Primary Phone:
Social Security #:
Email:
School:
Grade:
PARENT/GUARDIAN INFORMATION
Father's Name:
Father's SSN#:
Father's Employer:
Work #:
Cell #:
Mother's Name:
Mother's SSN#:
Mother's Employer:
Work #:
Cell #:
Party Responsible for Payment (Full Name):
Address
City
State
Zip
Signature:
Date:
MM slash DD slash YYYY
DENTAL INSURANCE
We will gladly assist you in filing the claims for your primary insurance if provided with the necessary information and a copy of the insurance card.
Mark for no dental insurance
- Mark for no dental insurance
Full name of the Policy Holder
Policy Holder SS#:
Policy Employer:
Policy Holder Birthday:
MM slash DD slash YYYY
Name of Insurance Company
Insurance Group #:
Member ID#:
I understand that payment is expected on the day of each service. I realize I am also responsible for any remaining charges that my insurance company chooses not to pay.
REFERRED BY
Name of Referral:
Relationship of Referral:
Or Referral By:
- Phone Book
- Newspaper
- Radio
- Website
- Facebook
- Other
DENTAL HEALTH INFORMATION
When was his/her last dental visit?
Name of previous dentist:
Does he/she have any current dental issues or concerns you would like to discuss or address
What (if anything) would he/she like to change about the appearance of their smile?
Does he/she have any fears about visiting the dentist (pain, cost, previous bad experience, lack of time, etc.)?
On a scale of 1 to 10 how would you rate his/her dental health? (1 being poor, 10 being excellent)
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
MEDICAL INFORMATION
Name of Primary Physician:
Date of last visit:
Any recent illness/doctor care or surgeries, please list:
List all medications he/she is currently taking:
All medical allergies
Other allergies:
Have you been told that he/she requires antibiotic pre-medication prior to dental treatment?
- Yes
- No
Why?
Pregnant
- Yes
- No
Nursing
- Yes
- No
Taking birth control pills
- Yes
- No
Has he/she ever been treated for or experienced any of the following? (Please check all that apply.)
- Sleep Disorder/Apnea
- CPAP Therapy/Machine
- Daytime Sleepiness
- Acid Reflux
- Clenching/Grinding of Teeth
Does he/she have a history of any of the following? (Please check all that apply.)
- AIDS
- Cortisone Treatments
- HIV Positive
- Respiratory Disease
- Anemia
- Diabetes
- Jaw Pain
- Rheumatic Fever
- Arthritis
- Epilepsy
- Kidney Disease
- Scarlet Fever
- Artificial Heart Valve
- Fainting
- Latex Allergy
- Seizures
- Artificial Joints
- Glaucoma
- Liver Disease
- Shortness of Breath
- Asthma
- Headaches
- Mitral Valve Prolapse
- Stroke
- Back Problems
- Heart Murmur
- Nervous Problems
- Swelling of Feet/Ankles
- Blood Thinners
- Heart Problems
- Pacemaker
- Thyroid Problem
- Cancer
- Phen-fen or Diet Pills
- Tobacco Habit
- Chemical Dependency
- Hemophilia
- Prolonged Bleeding
- Tuberculosis
- Chemotherapy
- Hepatitis
- Psychiatric Care
- Ulcer
- Circulatory Problem
- High Blood Pressure
- Radiation Treatment
- Venereal Disease
Describe Your Heart Problem:
Other:
PEDIATRIC QUESTIONNAIRE
1. Does your child snore or breathe heavily at night?
- Yes
- No
How often and how loud?
2. Do you notice your child breathing through their mouth?
3. Does your child grind his or her teeth?
4. Does your child move around or are they restless when they sleep?
5. Does your child seem hyperactive or have they been diagnosed with ADHD?
6. Does your child have any history of habits such as pacifier or thumb sucking, lip biting, etc?
7. Does your child have allergy issues or frequent sore throat/ear infections?
8. Does your child have any issues wetting the bed?
HIPAA FORM
- I HAVE BEEN OFFERED AND/OR RECEIVED A COPY OF GROVE DENTAL ASSOCIATES’ NOTICE OF PRIVACY PRACTICES
- I UNDERSTAND THAT MY PHI (PROTECTED HEALTH INFORMATION) CAN AND WILL BE USED FOR PURPOSES OF TREATMENT AND FOR PAYMENT FROM BOTH MYSELF AND/OR THIRD PARTY. I UNDERSTAND THAT I MAY REQUEST A COPY OF THE PRIVACY POLICIES AT ANY TIME.
- I UNDERSTAND I MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT
I GIVE CONSENT FOR THE OFFICE OF GROVE DENTAL ASSOCIATES TO SHARE PERSONAL INFORMATION REGARDING APPOINTMENTS, TREATMENT, BALANCE, ETC, WITH THE FOLLOWING FAMILY MEMBERS / SPOUSE/FRIENDS/OTHER.
PLEASE LIST NAME / RELATIONSHIP AND SIGN BELOW OR PLEASE WRITE NO ONE IF YOU DO NOT WANT YOUR INFORMATION SHARED WITH ANYONE,
1. Name / Relationship
2. Name / Relationship
3. Name / Relationship
PRINT PATIENT NAME

PRINT PATIENT NAME
PATIENT SIGNATURE OR PARENT/GUARDIAN SIGNATURE IF PATIENT IS A MINOR (UNDER 18)

PATIENT SIGNATURE
OR PARENT/GUARDIAN SIGNATURE IF PATIENT IS A MINOR (UNDER 18)
Date
MM slash DD slash YYYY
CAPTCHA

Website Manual

Files Coming Soon!

WELCOME,FROM CAPULIN CREATIVE

We are so glad you’ve trusted us to help you with your business. Below, you’ll find forms to submit blog post requests, social media content, and new project requests. If you have any questions, please reach out!

Your Content

New Project Request

Please use this form to request new projects from Capulin Creative

Blog Post Request

Please use this form to request new projects from Capulin Creative

NEW PATIENT INFORMATION

ABOUT YOU

SPOUSE INFORMATION

DENTAL INSURANCE

REFERRED BY

DENTAL HEALTH INFORMATION

MEDICAL INFORMATION

HIPAA FORM

Logo Files

PLEASE SELECT AN ITEM

Brand Guideline

PLEASE SELECT AN ITEM

Print Files

PLEASE SELECT AN ITEM

Digital Files

PLEASE SELECT AN ITEM

Digital Photos

PLEASE SELECT AN ITEM

Digital Resources

PLEASE SELECT AN ITEM

Media Content Form

NEW PATIENT INFORMATION | Minor Child

ABOUT YOU

PARENT/GUARDIAN INFORMATION

DENTAL INSURANCE

REFERRED BY

DENTAL HEALTH INFORMATION

MEDICAL INFORMATION

PEDIATRIC QUESTIONNAIRE

HIPAA FORM

Website Manual

WELCOME,
FROM CAPULIN CREATIVE